Beliefs about asthma and complementary and alternative medicine in low-income inner-city African-American adults

Inhaler Non-Adherence, Associated Factors and Asthma Control among Asthma Patients in a Tertiary Level Hospital in Tanzania

BACKGROUND

Inhaled medications including corticosteroids are the most effective long-term controller medicines for asthma-related chronic airway inflammation. Despite this fact, 30% to 70% of the uncontrolled asthma patients report non-adherence to their inhalers. This study investigated factors affecting inhaler non-adherence among outpatient asthma patients in Muhimbili National Hospital, Dar es Salaam Tanzania and related the level of inhaler adherence to the extent of asthma control.

METHODS

A cross-sectional hospital-based study was conducted among patients with bronchial asthma in the pulmonology clinic of Muhimbili National Hospital in Dar-es-salaam, Tanzania. Patients' demographic, clinical and socio-economic factors were collected using a structured questionnaire. Medication adherence was self-reported using a 10-item Test of Adherence to Inhalers (TAI) questionnaire. Adherence was gauged as good when the score was 50, intermediate (score 46-49) or poor (score ≤ 45). Asthma control was assessed using a 5-question Asthma Control Test (ACT). A score of ≥20 meant well controlled asthma while a score of ≤19 meant poorly controlled asthma. Patients' inhaler use technique was assessed using a 10-step checklist. Patient's technique was regarded correct when all the steps were performed correctly. Categorical data were summarised as proportions. Binary logistic regression was performed to identify factors associated with inhaler non-adherence. Significance level was set at p-value less than .05.

RESULTS

A total of 385 asthma patients were enrolled in the study. Females were 206 (53.5%), 232(60.3%) were non-adherent to medications and 283(73.5%) had poorly controlled asthma. Lack of health insurance, fear of medication side effects, being too busy, having alternative medication for asthma and incorrect inhaler technique were significantly associated with non-adherence to inhalers, all p-values <.05.

CONCLUSION

The magnitude of inhaler non-adherence and poorly controlled asthma were very high. Promoting adherence through patients' education on asthma and its management, emphasis on patients' insurance coverage and setting aside time to care for ones' self are fundamental in optimising asthma care and treatment.

Real-world Drivers Behind Communication, Medication Adherence, and Shared Decision Making In Minority Adults with Asthma

Background:

Inhaled corticosteroids (ICS) are the foundation of asthma management. However, ICS non-adherence is common. Black adults have lower ICS adherence than white adults, which likely contributes, in part, to the asthma disparities that Black adults experience.

Objective:

To explore how Black adults with uncontrolled asthma and their primary care providers communicated about ICS non-adherence and used shared decision-making to identify strategies to increase ICS use.

Design:

Eighty routine clinical visits for uncontrolled asthma were audio recorded and inductively analyzed using methods adapted from grounded theory methodology.

Participants:

Study participants included 80 Black adults (83% female) largely low-income (83% Medicaid) and their 10 primary care providers. The study settings were 2 Federally Qualified Health Centers.

Key Results:

Three overarching themes were identified: (1) ICS misuse and lack of knowledge; (2) external influences informed personal misconceptions about ICS; and (3) patient-provider communication to individualize plan of care.

Conclusions:

Reasons for ICS non-adherence in Black adults with uncontrolled asthma offer potential targets for interventions that facilitate enhanced adherence. Future research should include PCP training on strategies that support patient-centered care, such as communication, shared decision-making and patient engagement.

African Americans Want a Focus on Shared Decision-Making in Asthma Adherence Interventions

BACKGROUND AND OBJECTIVE

Inhaled corticosteroids (ICS) reduce asthma-related morbidity and mortality. However, ICS non-adherence is more common in African American (AA) adults than White adults and explains, in part, the marked asthma disparities that AAs experience. We aimed to understand how ICS non-adherence could be addressed from the perspective of AA adults with asthma, their family, and friends.

METHODS

We held six focus groups at two urban federally qualified health centers separately with adult asthma patients (n = 2), patients' family/friends (n = 2), and patients and family/friends together (n = 2). Qualitative descriptive methodology guided the design and the conduct of focus groups. Verbatim transcripts were analyzed by three coders working independently using conventional content analysis to capture responses to interview questions and identify emergent categories.

RESULTS

Forty-six AA adults participated (32 patients, 14 family/friends); 67% were female. Participants stated that ICS adherence could be improved if they were heard, respected, and received patient-centered care, and if providers highlighted the risk of ICS non-adherence at clinic visits. Though not explicitly described by participants as shared decision-making (SDM), what they described included many essential elements of SDM.

CONCLUSIONS

Participants desired SDM and offered reasons for ICS non-adherence that could be used to inform an SDM intervention for clinical application. Strategies informed by the recipients of care and delivered by providers during routine office visits offer a scalable approach to narrowing asthma disparities experienced by AA adults.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03036267.

A Scoping Review of International Barriers to Asthma Medication Adherence Mapped to the Theoretical Domains Framework

BACKGROUND

Internationally, adult asthma medication adherence rates are low. Studies characterizing variations in barriers by country are lacking.

OBJECTIVE

To conduct a scoping review to characterize international variations in barriers to asthma medication adherence among adults.

METHODS

MEDLINE, EMBASE, Web of Science (WOS), and CINAHL were searched from inception to February 2017. English-language studies employing qualitative methods (eg, focus groups, interviews) were selected to assess adult patient- and/or caregiver-reported barriers to asthma medication adherence. Two investigators independently identified, extracted data, and collected study characteristics, methodologic approach, and barriers. Barriers were mapped using the Theoretical Domains Framework and findings categorized according to participants' country of residence, countries' gross national income, and the presence of universal health care (World Health Organization definitions).

RESULTS

Among 2942 unique abstracts, we reviewed 809 full texts. Among these, we identified 47 studies, conducted in 12 countries, meeting eligibility. Studies included a total of 2614 subjects, predominately female (67%), with the mean age of 19.1 to 70 years. Most commonly reported barriers were beliefs about consequences (eg, medications not needed for asthma control, N = 29, 61.7%) and knowledge (eg, not knowing when to take medication, N = 27, 57.4%); least common was goals (eg, asthma not a priority, N = 1, 2.1%). In 27 studies conducted in countries classified as high income (HIC) with universal health care (UHC), the most reported barrier was participants' beliefs about consequences (N = 17, 63.3%). However, environmental context and resources (N = 12, 66.7%) were more common in HIC without UHC.

CONCLUSION

International adherence barriers are diverse and may vary with a country's sociopolitical context. Future adherence interventions should account for trends.

Perceptions of childhood asthma and its control among Malays in Malaysia: a qualitative study

Children with poor asthma control have poor health outcomes. In Malaysia, the Malays have the highest asthma prevalence and poorest control compared to other ethnicities. We aimed to explore Malay children with asthma and their parents' perceptions on asthma and its control. We conducted focus group discussions (FGD) using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and analysed thematically. Sixteen children and parents (N = 32) participated. The perception of asthma was based on personal experience, cultural and religious beliefs, and there was mismatch between children and parents. Parents perceived mild symptoms as normal, some had poor practices, raising safety concerns as children were dependent on them for self-management. Conflicting religious opinions on inhaler use during Ramadhan caused confusion in practice. Parents perceived a lack of system support towards asthma care and asthma affected quality of life. Urgent intervention is needed to address misconceptions to improve asthma care in children.

Home remedy use and influenza vaccination among African American and white adults: An exploratory study

Racial disparities in influenza vaccination persist between African American and White adults. It is critical to explore the reasons behind this disparity, which may be linked to the use of "folk" or home remedies for illness prevention and treatment. For this study, The GfK Group was contracted to conduct a nationally-representative survey (n = 819 African American and 838 White respondents). Respondents were asked about behaviors, attitudes, and risk perception related to the influenza vaccine, as well as frequency of home remedy use. Results were analyzed using adjusted logistic regression with 95% confidence intervals. In comparison to those who never use home remedies, those who use home remedies often or almost always were less likely to get vaccinated for influenza (respectively, OR = 0.70, CI 0.49, 0.99; OR = 0.27, CI 0.15, 0.49), less likely to be in favor of the vaccine (OR = 0.47, CI 0.33, 0.67; OR = 0.19, CI 0.10, 0.34), less likely to trust the vaccine (OR = 0.42, CI 0.29, 0.61; OR = 0.34, CI 0.20, 0.61), and more likely to perceive higher risk of vaccine side effects (OR = 1.79, CI 1.19, 2.68; OR = 4.00, CI 2.38, 6.73). These associations did not vary by race. Home remedy users may hold negative views toward the influenza vaccine, such that a combination of little trust in the vaccine process, and overestimation of risk associated with the vaccine itself, may contribute to vaccine refusal. Health care professionals can use these findings to tailor advice toward individuals with a preference for home remedy use to allay fears and correct misconceptions surrounding influenza and its vaccine.

Shared decision-making in the BREATHE asthma intervention trial: A research protocol

AIM

To evaluate the preliminary effectiveness of the BRief Evaluation of Asthma THerapy intervention, a 7-min primary care provider-delivered shared decision-making protocol that uses motivational interviewing to address erroneous asthma disease and medication beliefs.

DESIGN

A multi-centre masked two-arm group-randomized clinical trial.

METHODS

This 2-year pilot study is funded (September 2016) by the National Institute of Nursing Research. Eight providers will be randomized to one of two arms: the active intervention (N = 4) or a dose-matched attention control (N = 4). Providers will deliver the intervention to which they were randomized to 10 Black adult patients with uncontrolled asthma (N = 80). Patients will be followed three months postintervention to test the preliminary intervention effects on asthma control (primary outcome) and on medication adherence, lung function, and asthma-related quality of life (secondary outcomes).

DISCUSSION

This study will evaluate the preliminary impact of a novel shared decision-making intervention delivered in a real world setting to address erroneous disease and medication beliefs as a means of improving asthma control in Black adults. Results will inform a future, large-scale randomized trial with sufficient power to test the intervention's effectiveness.

IMPACT

Shared decision-making is an evidence-based intervention with proven effectiveness when implemented in the context of labour- and time-intensive research protocols. Medication adherence is linked with the marked disparities evident in poor and minority adults with asthma. Addressing this requires a novel multifactorial approach as we have proposed. To ensure sustainability, shared decision-making interventions must be adapted to and integrated into real-world settings.

TRIAL REGISTRATION

Registered at clincialtrials.gov as NCT03036267 and NCT03300752.

Barriers to medication adherence in asthma: The importance of culture and context

OBJECTIVE

Significant disparities exist in asthma outcomes. Racial and ethnic minorities have lower controller medication adherence, which may contribute to differences in asthma morbidity between minority and non-minority groups. The objective of this review is to identify individual, patient-provider communication, and systems issues that contribute to this pattern of medication underuse and to discuss potential strategies for intervention.

DATA SOURCES

Data were gathered from numerous sources, including reports of pharmacy and medical records, observational studies, and trials.

STUDY SELECTIONS

Studies analyzed factors contributing to patterns of asthma medication adherence that differ by race and ethnicity.

RESULTS

There is clear evidence of underuse of asthma controller medications among racial and ethnic minorities in prescription receipt, prescription initiation, and medication use once obtained. Individual factors such as medication beliefs and depressive symptoms play a role. Provider communication is also relevant, including limited discussion of complementary and alternative medicine use, difficulties communicating with patients and caregivers with limited English proficiency, and implicit biases regarding cultural differences. Systems issues (eg, insurance status, cost) and social context factors (eg, exposure to violence) also present challenges. Culturally informed strategies that capitalize on patient strengths and training providers in culturally informed communication strategies hold promise as intervention approaches.

CONCLUSION

Disparities in controller medication use are pervasive. Identifying the sources of these disparities is a critical step toward generating intervention approaches to enhance disease management among the groups that bear the greatest asthma burden.

Conducting an Integrative Health Interview

Complementary medicine incorporates the use of non-evidence-based complementary modalities into conventional (Western) medicine. Alternative medicines are approaches that are used in place of conventional medicine. Integrative medicine is the synthesis of conventional medical treatments with "evidence-based" complementary medical practices. When complementary approaches are incorporated into mainstream health care, it is called integrative health (IH). Among children and adults, IH is common despite not all therapies being safe and/or effective. Clinicians have suboptimal knowledge of their patients' IH use because, in part, they do not know what questions to ask and/or do not have a standard intake form to collect an IH history, as recently demonstrated by an American Academy of Allergy, Asthma, and Immunology membership survey. To address this unmet need, a group of Complementary and Alternative Practice in Allergy Committee members and interprofessional collaborators reviewed the existing literature to locate IH history forms that could assist in identifying patients' IH use. When none was located, the group created 3 templates for the systematic collection and documentation of IH practices: 2 general screening surveys that could be given to patients to complete before an appointment and a third template that provides the clinician with open-ended questions to help uncover IH practices in culturally diverse patient populations. Specialists, already acknowledged as skillful interviewers, can expand their patient-centered expertise by developing their own IH competencies.

Use of ethnic spices by adults in the United States: An exploratory study

Background: The use of complementary and alternative medicine (CAM) therapies has increased in the United States, but little is known about consumers' perceptions of use of such therapies. The purpose of this study was to assess knowledge, perceptions, and predictors of spice use for health promotion among adults in the Midwestern US. Methods: UUsing a cross-sectional study design, adults in the Midwestern US (n = 703) completed a valid and reliable survey which was pilot tested with a small convenience sample of adults (n = 38). The study variables included demographic profile, spice use behavior, perceptions about efficacy of spices, and willingness to use spices. Data were analyzed using SPSS to compute descriptive (e.g. percent and frequencies) and inferential statistics (i.e. logistic regression analyses). Results: Almost half of the participants were interested in learning about health benefits of spices (48%), indicated friends and family members as sources of information on spices (50%),and were willing to use spices as CAM therapies (51%). Most (>50%) of the participants were familiar with or had used eight out of the 10 listed spices. The majority of participants (54%)were currently using one or more spices on a daily basis and believed that ginger (64%), garlic(58%), and cinnamon (56%) could promote good health and wellness. In logistic regression analysis, age, gender (odds ratios [OR] = 1.44 and OR = 1.56), income (OR = 1.77), health status(OR = 2.01), and recommendations from healthcare providers (OR = 5.31 and OR = 3.96) were significant predictors of current spice use and willingness to use spices. Conclusion: Individuals in our study did not use many ethnic spices and were unaware of potential health benefits of spices. Greater awareness of ethnic spices for disease prevention and health promotion are needed in this population.

Prevalence and pattern of usage of complementary and alternative medicine among south Indian asthma patients in a tertiary care hospital

OBJECTIVES

The study aimed to investigate the prevalence of CAM users among asthmatic patients in a tertiary care South Indian hospital.

METHODS

Prospective, cross sectional study was conducted in 394 asthmatic patients.

RESULTS

30.4% of the patients used CAM therapies. The most commonly used CAM treatment was herbal medicine followed by pranayama (controlled breathing exercises). Most of the CAM users were found to be in lower middle class. The baseline characteristics of the CAM users and the non CAM users were found to be similar except for education and socioeconomic status (p < .008). Among the CAM users, none of the patients disclosed about their CAM treatment to their pulmonologists.

CONCLUSION

Patients must be educated about CAM therapies and they must be advised to discuss all their treatment related issues with treating clinicians. Healthcare professionals should be familiar with the merits and demerits of using CAM therapy so that they could provide proper guidance to their patients.

Lesson From Comparison of CAM Use by Women With Female-Specific Cancers to Others: It's Time to Focus on Interaction Risks With CAM Therapies

There has been no examination as to whether the prevalence of complementary and alternative medicine (CAM) use, as well as personal factors associated with CAM use and predictive of CAM use for women with female-specific cancers, is similar to those in other diagnostic groups. The purpose of this review is to compare CAM use and personal factors associated with and predictive of CAM use by women with female-specific cancers to samples of other diagnostic groups. If it is the case that CAM use is similar across various types of samples, then it may be unnecessary to continue to study detailed CAM use by those in separate diagnostic groups and instead focus energies on the examination of CAM therapies that may have risks for interaction with conventional therapies, such as biologically based therapies. The researcher concludes that we are now in an era in which we need to use our restricted time, human resources, and finances to examine biologically based CAM use that may carry high risks for interactions or toxicities for specific groups under examination, rather than examine global CAM use, unless the situation warrants such all-inclusive study.

Changes in clinical conversations when providers are informed of asthma patients' beliefs about medication use and integrative medical therapies

OBJECTIVES

To explore whether patient's personal beliefs about inhaled corticosteroid (ICS) and integrative medicine (IM) are discussed at routine primary care visits for asthma.

BACKGROUND

Negative medication beliefs and preferences for IM can be salient barriers to effective asthma self-management.

METHOD

A qualitative analysis of transcripts from 33 audio-recorded primary care visits using conventional content analysis techniques.

RESULTS

Four themes emerged when providers had knowledge of patient's beliefs: negative ICS beliefs, IM use for asthma, decision-making and healthy lifestyles. Two themes were identified when providers did not have this knowledge: asthma self-management and healthy lifestyles.

CONCLUSION

When providers had knowledge of their patient's IM endorsement or negative ICS beliefs, they initiated conversations about these modifiable beliefs. Without training in IM and in effective communication techniques, it is unlikely that providers will be able to effectively engage in shared decision-making aimed at improving asthma self-management.

An overview of integrative therapies in asthma treatment

Treatment of asthma lends itself to an integrative medicine approach due to the multifactorial nature of the disease. It is well established that asthma has a neuromuscular component (bronchospasm), an immunological component (inflammation), and a psychological component. This encourages the use of diverse approaches to address all avenues of pathophysiology, aiming for the most effective blend of treatment approaches possible. Integrative medicine is defined by NIH NCCAM ( http://nccam.nih.gov ) as medicine that blends the use of evidence-based complementary therapies with conventional medicine. Statistics from the 2007 National Health Interview Survey (NHIS), conducted by the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS), showed that approximately four out of 10 adults and approximately one in nine children and more than 50 % of children living with chronic illness, including asthma, used complementary therapies in the USA in 2007. Asthma and allergies rank among the top 15 most common medical conditions in which integrative therapies are used in both children and adults. To date, integrative treatment approaches with some evidence for benefit in asthma treatment include the following: nutrition modification, mind-body medicine, physical activity, and certain dietary supplement interventions.

Inhaled corticosteroid beliefs, complementary and alternative medicine, and uncontrolled asthma in urban minority adults

BACKGROUND

Many factors contribute to uncontrolled asthma; negative inhaled corticosteroid (ICS) beliefs and complementary and alternative medicine (CAM) endorsement are 2 that are more prevalent in black compared with white adults.

OBJECTIVES

This mixed-methods study (1) developed and psychometrically tested a brief self-administered tool with low literacy demands to identify negative ICS beliefs and CAM endorsement and (2) evaluated the clinical utility of the tool as a communication prompt in primary care.

METHODS

Comprehensive literature reviews and content experts identified candidate items for our instrument that were distributed to 304 subjects for psychometric testing. In the second phase content analysis of 33 audio-recorded primary care visits provided a preliminary evaluation of the instrument's clinical utility.

RESULTS

Psychometric testing of the instrument identified 17 items representing ICS beliefs (α = .59) and CAM endorsement (α = .68). Test-retest analysis demonstrated a high level of reliability (intraclass correlation coefficient = 0.77 for CAM items and 0.79 for ICS items). We found high rates of CAM endorsement (93%), negative ICS beliefs (68%), and uncontrolled asthma (69%). CAM endorsement was significantly associated with uncontrolled asthma (P = .04). Qualitative data analysis provided preliminary evidence for the instrument's clinical utility in that knowledge of ICS beliefs and CAM endorsement prompted providers to initiate discussions with patients.

CONCLUSION

Negative ICS beliefs and CAM endorsement were common and associated with uncontrolled asthma. A brief self-administered instrument that identifies beliefs and behaviors that likely undermine ICS adherence might be a leveraging tool to change the content of communications during clinic visits.

Urban adults' perceptions of factors influencing asthma control

OBJECTIVE

To identify urban adults' perceptions of facilitators and barriers to asthma control, including the role of self-care, medications, environmental trigger remediation, and primary care.

METHODS

Semi-structured open-ended qualitative interviews were conducted. Audio recordings were transcribed verbatim and entered into NVivo 10.0 (QSR International Pty Ltd, Doncaster, Victoria, Australia) for coding, analysis, and integration with demographic and asthma control data. RESULTS were analyzed by the level of asthma control. A modified grounded theory approach was used in the analysis.

RESULTS

Thirty-five adults with persistent asthma (94% Black; 71% female; 71% with uncontrolled asthma) from the five West Philadelphia zip codes with the highest asthma burden participated. Generally, all participants understood the roles of inhaled corticosteroid (ICS) and short-acting β-2 agonist (SABA) therapies in asthma self-care although they attributed systemic side effects to topical ICS administration. Compared with participants with controlled asthma, uncontrolled participants reported overusing SABAs, underusing ICS, rejecting medical and trigger remediation advice, having more negative experiences with primary care providers, and preferring more unconventional strategies to prevent or manage asthma symptoms.

CONCLUSIONS

Personal health beliefs about control can undermine adherence to medical and environmental remediation advice and likely contributes to high rates of uncontrolled asthma in this population. Clinicians need to know whether, and to what degree, these health beliefs can be modified. It is likely that new models of care, such as patient-centered shared decision-making approaches, and new partners, such as community health workers, may be required to modify these beliefs. This would be an important first step to enhance asthma control in vulnerable populations.

Using the theory of planned behavior to explore attitudes and beliefs about dietary supplements among HIV-positive Black women

BACKGROUND

This cross-sectional study investigated whether the theory of planned behavior (TPB) constructs: attitudes, subjective norms, and perceived behavioral control were related to intention of dietary supplements use among African-American women living with Human Immunodeficiency Virus and/or Acquired Immune Deficiency Syndrome (HIV/AIDS).

METHODS

A closed-ended questionnaire based on the TPB was utilized to explore the use of dietary supplements among a cohort of 153 HIV-positive African-American women.

RESULTS

Overall, 45% of the respondents used dietary supplements to manage/control their HIV. Combined, attitudes, subjective norms and perceived behavioral control were significant predictors of intention toward dietary supplement use (69% of the variance explained, p<0.0001). Attitudes (β=0.23, p<0.001) and perceived behavioral control (β=0.45, p<0.0001) were found to be significant independent predictors of intention. Behavioral intention and proximal TPB constructs (attitudes, subjective norms, and perceived behavioral control), as well as their underlying beliefs about dietary supplements use, were all found to be significantly more positive in users of dietary supplements compared to non-users (p<0.001).

CONCLUSIONS

Results showed that attitudes, subjective norms and perceived behavioral control are important predictors in the intention to use dietary supplements for control of HIV among African-American women. Implications from this study suggest that the TPB can be used to better identify and understand salient beliefs that surround intentions to use alternative therapies for management of disease. These beliefs can be used to develop interventions surrounding HIV treatment and care.

Complementary and alternative medicine use and asthma: relation to asthma severity and comorbid chronic disease

OBJECTIVE

To determine (a) the prevalence of complementary and alternative medicine (CAM) use among people with asthma, and (b) if comorbid chronic disease and asthma severity are associated with CAM use.

METHODS

This cross-sectional study utilized data from n = 15 276 adults who participated in the 2009 Behavioral Risk Factor Surveillance System (BRFSS) and the 2009 Asthma Callback Survey (ACBS). Binary Logistic regression was used to determine if comorbid disease and asthma severity were associated with CAM use (yes/no). Model covariates were age, sex, income, and education.

RESULTS

About 26% of respondents report using at least one form of CAM. The most frequently reported form of CAM use is breathing exercises (19.8%). The results indicate that neither comorbid cardiovascular disease, diabetes, nor stroke are related to CAM use, but individuals with more severe asthma symptoms were more likely to use CAM (OR = 1.05, 95% CI 1.04, 1.05).

CONCLUSIONS

CAM remedies most often reported by people with asthma (breathing techniques, vitamins) are unlikely to pose safety risks. Comorbid chronic disease does not motivate people with asthma to seek unconventional remedies. The increase in CAM use with asthma severity prompts questions about factors that might drive this behavior, such as untreated/inadequately treated disease, or medication side effects.

Complementary and alternative asthma treatments and their association with asthma control: a population-based study

OBJECTIVES

Many patients with asthma spend time and resources consuming complementary and alternative medicines (CAMs). This study explores whether CAM utilisation is associated with asthma control and the intake of asthma controller medications.

DESIGN

Population-based, prospective cross-sectional study.

SETTING

General population residing in two census areas in the province of British Columbia, Canada. Recruitment was based on random-digit dialling of both landlines and cell phones.

PARTICIPANTS

486 patients with self-reported physician diagnosis of asthma (mean age 52 years; 67.3% woman).

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed CAM use over the previous 12 months, level of asthma control as defined by the Global Initiative for Asthma and the self-reported intake of controller medications. Multivariate logistic regression was performed to study the relationship between any usage of CAMs (outcome), asthma control and controller medication usage, adjusted for potential confounders.

RESULTS

A total of 179 (36.8%) of the sample reported CAM usage in the past 12 months. Breathing exercises (17.7%), herbal medicines (10.1%) and vitamins (9.7%) were the most popular CAMs reported. After adjustment, female sex (OR 1.66; 95% CI 1.09 to 2.52) and uncontrolled asthma (vs controlled asthma, OR 2.25, 95% CI 1.30 to 3.89) were associated with a higher likelihood of using any CAMs in the past 12 months. Controller medication use was not associated with CAM usage in general and in the subgroups defined by asthma control.

CONCLUSIONS

Clinicians and policy makers need to be aware of the high prevalence of CAM use in patients with asthma and its association with lack of asthma control.

A systematic review of complementary and alternative medicine for asthma self-management

This article is a systematic review of complementary and alternative medicine use for pediatric and adult asthma self-management. The aim of the review was to summarize the existing body of research regarding the types and patterns of, adverse events and risky behaviors associated with, and patient-provider communication about complementary therapies in asthma. This evidence serves as the basis for a series of recommendations in support of patient-centered care, which addresses both patient preferences for integrated treatment and patient safety.

Health beliefs, treatment preferences and complementary and alternative medicine for asthma, smoking and lung cancer self-management in diverse Black communities

OBJECTIVE

The purpose of this literature review is to characterize unconventional health beliefs and complementary and alternative medicine (CAM) for asthma, smoking and lung cancer as those that are likely safe and those that likely increase risk in diverse Black communities. These findings should provide the impetus for enhanced patient-provider communication that elicits patients' beliefs and self-management preferences so that they may be accommodated, or when necessary, reconciled through discussion and partnership.

METHODS

Original research articles relevant to this topic were obtained by conducting a literature search of the PubMed Plus, PsychINFO and SCOPUS databases using combinations of the following search terms: asthma, lung cancer, emphysema, chronic obstructive pulmonary disease (COPD), smoking, beliefs, complementary medicine, alternative medicine, complementary and alternative medicine (CAM), explanatory models, African American, and Black.

RESULTS

Using predetermined inclusion and exclusion criteria, 51 original research papers were retained. Taken together, they provide evidence that patients hold unconventional beliefs about the origins of asthma and lung cancer and the health risks of smoking, have negative opinions of standard medical and surgical treatments, and have favorable attitudes about using CAM. All but a small number of CAM and health behaviors were considered safe.

CONCLUSION

When patients' unconventional beliefs and preferences are not identified and discussed, there is an increased risk that standard approaches to self-management of lung disease will be sub-optimal, that potentially dangerous CAM practices might be used and that timely medical interventions may be delayed.

PRACTICE IMPLICATIONS

Providers need effective communication skills as the medical dialog forms the basis of patients' understanding of disease and self-management options. The preferred endpoint of such discussions should be agreement around an integrated treatment plan that is effective, safe and acceptable to both.

Use of complementary and alternative medicine among asthmatic patients in primary care clinics in Malaysia

OBJECTIVES

This study aimed to determine the knowledge about asthma and the prevalence, disclosure and evaluation of the use of complementary and alternative medicine (CAM) among asthmatic patients.

METHODS

This cross-sectional study was conducted on 95 patients diagnosed with asthma in a primary healthcare centre in Kuala Lumpur, Malaysia using a self-administered questionnaire.

RESULTS

Ninety-five patients with a mean age of 47.06 years (±12.8) participated, the majority were female (66.7%), Malay (72.6%). The prevalence of ever-CAM use was 61.1%. The non-ever-CAM users' mean age was 51±13.9 years while the ever-CAM users' mean age was 44.5 ±11.5 years (P = 0.021). Sixty-three females (66.8%) used CAM compared to 14 males (43.8%) (P = 0.014). Thirty-six (62.1%) CAM users had not discussed use of CAM with their doctors. The main reason of non-disclosure was the doctor never asked (55.6%), and the main sources of information about CAM were family and relatives (46.6%). There was no significant difference between use of CAM and knowledge about asthma. The majority of asthmatic patients used rubs (39%), foods (16.9%) and herbs (16.9%). About 76% of asthmatic patients perceived CAM as good for their disease management. On linear multiple regression, Malay race (P = 0.026) and female gender (P = 0.006) were significant predictors of CAM use.

CONCLUSION

Use of CAM among asthmatic patients is relatively high, particularly among females. The majority of asthmatic patients valued the use of CAM. Non-disclosure was high in this study. Health education of asthmatic patients about CAM is highly recommended.

Perspectives on complementary and alternative therapies in asthma

Asthma is a chronic disease that affects millions of individuals living in the USA. Proper asthma management is essential for controlling asthma symptoms and exacerbations. In recent years, however, there has been increased recognition of individuals using complementary and alternative medicine (CAM) to treat asthma. This article reviews the status of the current literature on various cultural factors that influence CAM use. In addition, current research of two widely used forms of CAM, herbal remedies and relaxation techniques, is presented. Future directions and recommendations to increase the methodological rigor of CAM research are discussed, particularly as they pertain to herbal remedies and relaxation strategies. The importance of well-designed research studies, including observational studies and randomized controlled trials, is highlighted.

Components of recommended asthma care and the use of long-term control medication among urban children with asthma

BACKGROUND

Previous research has documented an underuse of long-term control medications among children with asthma, in nonadherence with national guidelines on asthma care.

OBJECTIVES

To determine if factors related to access and quality of asthma care are associated with underuse of long-term control medication among children with asthma.

RESEARCH DESIGN

A parent-report cross-sectional survey conducted in 26 randomly selected New York City public elementary schools.

SUBJECTS

Five thousand two hundred fifty children, of whom 912 had asthma.

RESULTS

Twenty-nine percent of children with asthma reported using a long-term control medication. Among children with persistent asthma, defined as having one or more sleep disturbances due to asthma per week, 59.0% reported using a long-term control medication. After adjusting for demographic factors, children who had an asthma plan, had visited a doctor in the previous 6 months for nonurgent asthma care, or were enrolled in an asthma education program were more likely to use long-term control medication (odds ratios: 6.00, 4.11, 2.88, respectively). Children of Spanish-speaking parents, African American children, and children with no health insurance were the least likely to use long-term control medication (odds ratios: 0.51, 0.49, 0.20, respectively). Children who reported recommended components of asthma care were the most likely to use their medication with appropriate frequency.

CONCLUSIONS

Children who reported markers of high quality, personalized medical care, were more likely to use long-term control medication. These findings illustrate that components of the medical care received, and not only the demographic characteristics of the patient, are key factors in understanding the underuse of long-term control medication in urban children with asthma.

Self-management of acute asthma among low-income urban adults

One approach to address asthma disparities has been to create evidence-based guidelines to standardize asthma care and education. However, the adoption of these recommendations has been suboptimal among many providers. As a result, low-income minority patients may not be receiving adequate instruction in asthma self-management. In addition, these patients may fail to follow guideline-based recommendations. We conducted 25 interviews to identify the extent to which urban low-income adults have received training in, and implement, self-management protocols for acute asthma. Twenty-five adults (92% female; 76% African American; mean age 39) were enrolled. Only one subject had received asthma self-management training and only 10 (40%) used short-acting beta-(2) agonist-based (SABA) self-management protocols for the early treatment of acute asthma. No subject used a peak flow meter or an asthma action plan. Most (52%) chose to initially treat acute asthma with complementary and alternative medicine (CAM) despite the availability of SABAs. Importantly, 21 (84%) preferred an integrated approach using both conventional and CAM treatments. Four themes associated with acute asthma self-management emerged from the qualitative analysis. The first theme safety reflected subjects' perception that CAM was safer than SABA. Severity addressed the calculation that subjects made in determining if SABA or CAM was indicated based on the degree of symptoms they were experiencing. The third theme speed and strength of the combination described subjects' belief in the superiority of integrating CAM and SABA for acute asthma self-management. The final themesense of identity spoke to the ability of CAM to provide a customized self-management strategy that subjects desired. It is unclear if subjects' greater use of CAM or delays in using SABA-based self-management protocols were functions of inadequate instruction or personal preference. Regardless, delays in, or under use of, conventional self-management protocols may increase the risk for an untoward outcome. To that end, all patents' acute asthma self-management strategies should be evaluated for their timeliness and appropriateness. This would be of particular importance for vulnerable populations who bear a disproportionate burden of the disease and who have the fewest resources.

Addressing asthma health disparities: a multilevel challenge

Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared with non-Latino white subjects. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex, and interrelated sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Several strategies that could be applied in clinical settings to reduce asthma disparities are described, including the need for routine assessment of the patient's beliefs, financial barriers to disease management, and health literacy and the provision of cultural competence training and communication skills to health care provider groups.

Eliminating asthma disparities: is there evidence of progress?

PURPOSE OF REVIEW

In spite of numerous efforts, asthma rates in the United States remain historically high and disparities persist among low-income and minority populations. This review assesses the current status of asthma inequities from the perspective of disease development, progression, and outcomes.

RECENT FINDINGS

Recent findings highlight the complex and multifactorial nature of asthma. There is a clear line of emerging evidence suggestive of important hierarchical relationships between the predisposed or affected individual and his or her intrapersonal life, familial relationships, social networks, and broader community.

SUMMARY

Approaches in basic, clinical, and translational asthma research must be modified to account for the social construct of race and to detangle complex interactions of contributing factors at and across the individual and community level. However, there are a number of obvious opportunities to dramatically reduce asthma disparities at hand.